Direct stenting is becoming the most frequently used technique in the treatment of coronary stenosis, since it is more cost-effective and less time-consuming. Furthermore, the higher periprocedural success rate and availability is leading to a higher case load. This may bare a higher frequency of less common complications, such as unwanted stent strut deformation. We recently encountered this complication during two cases of direct stenting, using two different cobalt chromium stents with very thin struts.
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We report a case of coronary stent fracture occurring after treatment of an ostial lesion in an anomalous right coronary artery arising from the left coronary sinus. Stent fracture occurred at the point of exit from the aortic wall. Analysis suggests that this junction between immobile and free segments of artery acted as a hinge point for repetitive stent flexion during the cardiac cycle, leading to metal fatigue and strut fracture. Examples like this demonstrate that unexpected complications can occur when using stents in unusual circumstances and that caution and surveillance may be necessary.
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Sudden cardiac arrest (SCA) a leading cause of death in the western world and coronary heart disease may be responsible for 60-80 % of these deaths. Consequently, an increasing number of these patients will be admitted directly for coronary intervention during automatic mechanical chest compression. Manually performed cardiopulmonary resuscitation (CPR) is not possible during percutaneous coronary intervention (PCI). However, mechanical chest compression devices may be an alternative. We report on two cases in which ongoing chest compression was associated with reversed diastolic blood flow in the left anterior descending coronary artery (LAD). This may be a sign of the development of ischaemic contracture despite adequate systemic blood pressure during mechanical chest compression.
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Acute coronary occlusions leading to myocardial infarctions tend to cluster in predictable “hot spots” within the proximal third of the coronary arteries. We describe the case of a 47 year old man with a complex cardiovascular risk profile presenting with unstable angina, in whom both coronary angiography and grey-scale intravascular ultrasound revealed a non-significant obstruction in the distal left main coronary artery. Virtual histology intravascular ultrasound analysis defined a vulnerable plaque, which made us apply a local plaque sealing strategy using a sirolimus-eluting stent.
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Percutaneous coronary intervention (PCI) is becoming increasing accepted as a viable treatment option for patients with left main coronary artery (LMCA) disease deemed unsuitable for coronary artery bypass grafting (CABG). Nonetheless, the risk of ischaemic complications during or after the procedure is considerable in such patients. Supportive techniques may limit ischaemia during PCI and maintain haemodynamic stability. The TandemHeart® is a percutaneous left ventricular assist device with a centrifugal continuous flow pump providing a systemic output of up to 4L/min through a retrograde femoral access, which can be deployeded percutaneously in the catheterisation laboratory at the time of the coronary procedure. Oxygenised blood is harvested trans-septally from the left atrium. The TandemHeart® may lead to sustained aortic valve closure because of a continuous supraventricular pressure maintained in the aorta. We report a case of successful PCI of the LMCA after implantation of a TandemHeart® device for circulatory support, This case is unusual in that the presence of the TandemHeart® led to temporary aortic valve closure and pulseless coronary flow throughout the interventional procedure.
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